Richards, Idawanna E. Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: NZ it
REQUESTED RETURN TIME: I�OI
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
MAC�It D RA
NAME: Z QR VJ Ru0!1 RTCPI (LD.S _ CASE # Z O
DATE OF CREMATION: 3Isl �
TIME STARTED: IZ- 5o Pn TIME COMPLETED:
//— 3;10 PO
TYPE OF CONTAINER: _ n �t {+uS - CCU �cAw ](��
PLACED IN RETORT: ` ' 1'60 Ph MOVED: J uSF1 L NO
PLACE OF DEATH: S��L��S `��1�� Zl� C���C stud- ,ct-V�c �+ CZ�C,�
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: Z60
DATE & TIME REMAINS ARRIVED AT CREMATORY: 3111 ZO II;30AM
PLACED IN HOLD:
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED: FVvl 1741(
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
NYS Department or OWL-
Division of Cemeteries
luthorization for Cremation and Disposition One Commerce Plaza,99 Washington Avenue
Albany,NY 12231
(518)474-6226
www.dos.state.ny.us
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date: 02/29/2020
Number: Z0l
Crematory Name: Pine View Crematorium
Phone: bse)�qf yr)
Address: -Quaker Road, Queensbur ,NY 12804
CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS.
Cremation is carried out by placing thesubjected to inten a heat and flamef the deceased and . The heat and flame wil7material
i container holding the nemains cinerate
cremation chamber where they are
consume everything except bone and metal, which are all that will be left after cremation.
Following cremation, the crematory will take reasonable efforts to remove all of the remains and o
the cremation chamber, but some minimal dust and residue will likely be left behind. The cremato
incidental and foreign material from the remains and the incidental and foreign material will be disposed of as
required by law. The cremated remains will be mechanically pulverized into small pieces and placed into a
designated container or urn; Cremated remains generally are pulverized until no single fragment is
recognizable as skeletal tissue.
OPENING OF CONTAINER.
The crematory may only open the container holding the un-cremated human remains in limited circumstances, such
as to confirm the identity of the deceased or to ensure that no material is enclosed which might injure employees or
damage crematory property. If human remains are delivered in a container which is not suitable for cremation
such as a ceremonial or rental casket, the crematory will require that the remains be moved into a suitable
container before it accepts the remains. The opening of a container or the transfer or removal of remains will be
conducted before a witness and will be done in privacy, with dignity and respect.
IDENTIFICATION OF DECEASED
Name of Deceased: Idawanna E. Richards
Marital Status: Married
Last Known Address: 33 Sisson Rd., Fort Edward,NY 12828
Place of Death: Saratoga Hospital, 211 Church St., Saratoga Springs,New York 12866
Sex: M OF Age: 79 DOB: 03/09/1940 Date of Death: 02/28/2020 Estimated Weight: Y n Oh
Description of casket/container in which remains will be delivered: Matthews Casket Co. Cremation Case
Cardboard top, plywood bottom
PERSON IN CONTROL OF DISPOSITION
(Person(s) in control of disposition, initial ONE of the following)
I am/We are the designated agent of the deceased designated in a will or written instrument executed
pursuant to Public Health Law section 4201.
-OR-
— I/We have no knowledge that the deceased executed a written instrument pursuant to Public Health Law
section 4201 or a will containing directions for the disposition bf his or her remains and (Continued next page)
Idawanna E. Richards
Name of Deceased Page 1 of
DOS-1898-f-I(Rev.01/10)
1 and
ave the
am/we are the person(s) having priority under Public Health Law
to the dec0eased h right
section s as follows:
authorize
:remation of the remains of the deceased. My/Our relationship
Insert from the list below)
dumber: 2 Description: husband
1. A person designated in writing pursuant to Public Health Law section 4201(3);
2. The surviving spouse;
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian;
of age or older entitled to share in the estate and who is/are closest in
7. Any person(s) eighteen years
relationship to the deceased;
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Public Health Law §4201(7);
10. A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court
Procedure Act;
10a. Any other person who is acting on behalf of the deceased and who has executed a written statement
pursuant to Public Health Law §4201(7)
(Initial ALL THREE of the following)
IMe hereby affirm that the body of the deceased does not contain a battery, battery pack, power cell,
radioactive implant, or radioactive device and that any such materials were removed prior to the execution of this
Authorization Form. Failure to remove these items prior to cremation may result in harm to the crematory and
crematory personnel.
Paul M. Dietrich
�—)&— IMe hereby affirm that instructions have been given to (funeral director name)
regarding the removal of any personal property or other thing of value which any person signing below or any family
member of the deceased wishes to preserve. (crematory name)
Pine View Crematorium is not
responsible for removal of personal items from the container or from the remains of the deceased. Personal items
left in the container or with the remains will be destroyed by the cremation process and cannot be retrieved
after cremation.
I/V11e hereby authorize (crematory name)
Pine View Crematorium to cremate the
remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is:
Name: Carleton Funeral Home, Inc.
Address: 68 Main Street, Hudson Falls,NY 12839
Phone: 518-747-4243
The cremated remains of deceased will be disposed of as follows:
L'd ✓� ID(.�/�u c 10.n
cc� It f:�7 -0
If for any reason the person named above does not take possession of the cremated remains,
(crematory name)
Pine View Crematory is authorized to give possession of the remains to
(funeral home name) Carleton Funeral Home, Inc. by delivery in person or by registered mail.
Idawanna E. Richards
Name of Deceased Page 2 of
DOS-1898-f-I(Rev.01/10)
Initial the following)
Me understand that if the remains are not claimed within
may dispose ose of the remains in an irretrievable manner,
days of cremation,
crematory name) Pine View Crematorium y p
,uch as by scattering.
3REMATION CONTAINERIURN
Initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from
Carleton Funeral Home, Inc.. and is described as follows:
Me understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
An urn has not yet been purchased. Me understand that if no urn is purchased or otherwise provided
Icrematoryname) Pine View Crematorium will place the cremated remains in a rigid temporary
container for delivery.
The Authorization Form was provided by (funeral director name) Paul M. Dietrich
was executed at (funeral home name) Carleton Funeral Home, Inc.
(funeral home address) 68 Main Street, Hudson Falls,NY 12839 and is signed by the funeral director
as witness to its execution.
Me have received a completed copy of this Authorization Form.
The person(s) identified below is/are the person(s) in control of disposition, who by signing this
Authorization Form, attests) to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s) the foregoing.
Signed this Z G -L- Iay of F-A-) 20 Z0 - R
Typed or Printed Name Signature v
Address
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Paul M. Dietrich
Funeral Director Typed or Printed Name
Fun re r Signature
14257
Registration Number
Idawanna E. Richards
Name of Deceased Page 3 of
DOS-1898-f-I(Rev.01110)